KR20110023094A - The device for delivering optimal tension safaely and effectively in cerclage annuloplasty procedure - Google Patents

Abstract

PURPOSE: An organ-protecting device and a knot-transmitting device for a coronary sinus and an atrioventricular valve, and a device for cerclage operating a mitral valve using the same are provided to adjust the tension of the cerclange thread and maintain the adjusted tension. CONSTITUTION: A cylindrical coronary sinus tube(22) is prepared. A cylindrical tube for an atrioventricular valve(24) protects the organs of the atrioventricular valve and the interventricular septum of heart. The coronary sinus tube and the tube for the atrioventricular valve are expanded and combined to form a step part(26). The step part forms a organ protective device(20). A knot-transmitting device is a hollow catheter and includes an open part and a through hole.

Description

TECHNICAL DEVICE FOR DELIVERING OPTIMAL TENSION SAFAELY AND EFFECTIVELY IN CERCLAGE ANNULOPLASTY PROCEDURE}

The present invention relates to a device for mitral valve circle large surgery that is used in mitral valve circle large surgery to be performed in patients with mitral regurgitation, and to serve to safely and effectively deliver and maintain the appropriate tension that is finally required in the circle large procedure. . Specifically, the tissue protection mechanism for protecting the coronary sinus and three thousand valves and the surrounding tissues in the mitral valve circle large procedure, and the knot of the circle large thread to transfer and maintain a constant tension to the circular large thread The present invention relates to a knot delivery device for delivering up to an upper end of a mitral valve, and a device for mitral valve circle large surgery including the two devices.

The heart is an organ that acts as a blood pump. To operate this muscle pump (heart) requires a valve that allows blood flow to flow in a constant direction rather than backflow. The heart has four rooms, two atriums and two ventricles, which are connected to four vessels: the aorta, veins, pulmonary arteries, and pulmonary veins.

The valve between the left atrium and the left ventricle is the mitral valve (MV), the valve between the right atrium and the right ventricle is the tricuspid valve (TV), and the valve between the left ventricle and the aorta is the aortic valve, the right ventricle and The valve between the pulmonary arteries is the pulmonary valve (PV).

The valve should open and close completely according to the heartbeat. If it does not move properly, such as not fully closed or fully open, fluid will flow back or flow badly. This is heart valve disease. Heart valve disease can be divided into two types: a disease that causes blood to leak completely (closure, regurgitation) and a disease that does not open completely when the valve needs to be closed (stenosis).

Mitral regurgitation is a disease in which the mitral valve, the valve between the left atrium and the left ventricle, does not close completely when it is closed, resulting in blood backflow, which results in a burden on the heart, which results in heart failure and eventually causes heart failure.

To date, treatment for mitral regurgitation is the standard treatment of surgery, which involves opening the sternum of the chest and opening the heart to repair the mitral valve or replace it with an artificial valve. This is a very invasive method of treatment that is effective but can occur as much as 5% of the risk of death of the patient due to surgery alone. Due to these limitations, until now only very severe mitral regurgitation has been treated with surgery. Against this backdrop, many studies have been made on the development of percutaneous mitral valve repair that can repair the mitral valve by relatively simple procedure using a catheter without opening the chest of the patient and requiring the incision of the heart. As part of this international study, we recently published a Mitral cerclage coronary sinus annuloplasty (MVA) in an international paper, which would apply circular pressure around the mitral annulus (MA). It can prove that the therapeutic effect is excellent. The contents of the paper have been filed in international patent applications (International Application No .: PCT / US2007 / 023836) and are now published internationally by the International Bureau (International Publication No. WO2008 / 060553).

Briefly describing the percutaneous mitral valve surgery (mitral circular surgery) described in the above paper and the patent application, the catheter is placed into the 'tubular sinus' after accessing the right atrium through the jugular vein and the 'proximal septal vein'. Pass the thread needed for the circle large with ')'. This thread can easily come out as one of the right ventricular outflow tracts (RVOTs). This thread can be easily grasped into the right atrium, thereby placing the circle large yarn in the tissue around the mitral annulus. Applying tension to the thread gives the effect of imprisoning the mitral valve, which reduces the incomplete closure of the valve by bringing the two valves of the mitral valve closer together. This principle has a very similar effect to the surgical treatment of direct mitral mitral mitral valve.

However, there remain some technical problems to be solved here.

First, there is a need for a tension locking device that can apply and maintain appropriate tension on the circle large yarn at the site of the procedure. According to the results of the present study published by the present inventors, a tension of about 400 g to 1200 g was required to obtain a therapeutic effect although it varies from individual to individual. The tension for each individual needs to be fixed in place after applying tension to the point where mitral regurgitation decreases through MRI, X-ray fluoroscopy or echocardiography during the procedure. And this tension must maintain the initial tension despite the constant heart rate resistance.

Second, because the tension is maintained by a relatively thin circular yarn-the previous study used 0.014 inches of nylon and its thickness could change-which could damage adjacent tissues. . In particular, since a large thread (cerclage suture) crosses the three thousand valve (TV), there may be damage to the valve function and damage to the valve and its accessories. The present invention is to propose a method for solving this problem by devising an apparatus that can overcome the disadvantages of the MVA.

An object of the present invention is to overcome the above disadvantages in MVA, and at the same time, to provide a device for mitral valve circle large procedure for the safe and effective delivery of the appropriate circle large tension in mitral valve circle large procedure (MVA).

Another object of the present invention is to provide a tissue protection mechanism for preventing tissue damage by the circle large yarn, and at the same time, the procedure should be easy and easily adjust the tension of the circle large yarn for each patient and easily fix it again. The circle large thread, which is fixed once, is not released after the procedure and provides a knot delivery device that can maintain a constant tension at all times.

The present invention is to achieve the above object, the apparatus for mitral valve circle large surgery to protect the tissue of the coronary sinus and three thousand valves of the present invention, and to deliver the knot to maintain the tension of the circle large thread (A) Coronary venous tube 22, which is a hollow cylindrical tube for protecting coronary sinus tissue, a triangular valve tube 24, which is a hollow cylindrical tube for protecting the tricuspid valve and the ventricular septum, and the coronary sinus Tissue protection mechanism (20) consisting of a stem portion 26 is fixed for each other extending for the tube and the three thousand valve tube for each; And (B) a hollow catheter, a knot delivery mechanism 30 having an opening part 32 that can be opened and closed at one end and a through hole 34 formed at a side of the opening part in a longitudinal direction.

According to a preferred embodiment, a stopper 24a is formed in the middle portion of the three thousand valve tube 24 to prevent the three thousand valve tube from further entering the myocardium. More preferably the stopper is an annular projection.

According to a preferred embodiment, the three thousand valve tube has a structure that is tapered toward the end, so as to wrap the circular yarn in the ventricular septum.

According to a preferred embodiment, the tubular sinus tube 22 is made of a soft and flexible material, the three thousand valve tube 24 and the stem portion 26 is relatively stronger than the tubular sinus tube Material is used.

According to a preferred embodiment, the opening and closing portion of the knot delivery mechanism is cut open by the cutter.

According to another preferred embodiment, the knot delivery mechanism 30 is composed of an external first tube 36 and a second tube 38 inserted into the first tube and rotatable within the first tube. The opening and closing part 32 is opened or closed by the rotation of the second tube 38. More preferably, the first tube 36 has a hole 37 having a length corresponding to the sum of the opening and closing portion length L1 and the length L2 of the through hole at one end thereof, and the second tube 38 is formed. Has a hole 39 having a length equal to or greater than the length of the first tube hole 37, wherein the hole 39 has a length equal to the length L1 of the opening and closing portion, and a width d2 is equal to or greater than the width d1 of the opening and closing portion. The inlet portion 39a and the inner portion 39b whose length is greater than or equal to the length L2 of the through hole and whose width d3 is larger than the sum of the width d2 of the inlet portion and the width d1 of the through hole.

As described above, the mitral valve circle large surgery apparatus of the present invention is composed of a tissue protection mechanism and a knot delivery mechanism.

Tissue protection mechanism can prevent damage to the circle large thread on the tissue, and the knot delivery mechanism delivers and maintains the knot of the circle large thread, adjusts the tension of the circle large thread and maintains the tension after adjusting the tension. It can be done.

Hereinafter, with reference to the accompanying drawings, to explain in more detail the tissue protection mechanism, knot delivery mechanism and apparatus for mitral valve circle large procedure comprising them in the coronary sinus and three thousand valves used in the mitral valve circle large procedure of the present invention Shall be.

First, the tissue protection mechanism 20 for protecting the coronary vein and three thousand valves used in the mitral valve circle large procedure will be described.

1 is a schematic diagram of a tissue protection mechanism in accordance with a preferred embodiment of the present invention, and more particularly, shows a tissue protection mechanism 20 inserted into a circular chamber 10.

Figure 2 is a front incision view of the heart showing the tissue protection mechanism is installed, according to a preferred embodiment of the present invention, Figure 3 is a side incision view of the heart.

A circle large thread (10, cerclage suture) is a very thin thread with a thickness of 0.014 ”or less used in the mitral cerclage coronary sinus annuloplasty (MVA), with one strand of coronary sinus It is named in the sense that the CS) part, tricuspid valve (TV) part, and ventricular septal part come out of the body in a circular shape, and when it comes out of the body, it becomes two strands of one end and the other end.

1 to 3, the tissue protection mechanism 20 of the present invention is a hollow cylindrical tube for protecting coronary sinus tissue (22), tricuspid valve and ventricular septum (heart muscle) Three thousand valve tube 24, which is a hollow cylindrical tube for protecting the tissue, and the coronary sinus tube and the three thousand valve tube extends to each other and is coupled to each other stem portion 26.

In general, tissue erosion in the mitral valve circle large procedure (MVA) is at risk in the coronary sinus (CS) area, in the tricuspid valve (TV) area, and in the ventricular septal (IVS) area. Correspondingly, in this part, the tissue protection mechanism 20 of the present invention surrounds the large yarn 10.

Some of the CS sections are protected by coronary protective devices (40), which have already been introduced in the MVA paper, so only the protection of these sections is necessary.

The tissue protection mechanism 20 of the present invention has two tubes separated from each other at the lower end and joined to each other at the upper end, and has a hollow cylindrical tube, that is, a lumen, and has a thickness of about 4 Fr diagnostic catheter. The material may be a soft rubber or plastic material. The present inventors have named the tissue protective mechanism 20 of the present invention 'CSTV protective device' or 'CSTV' in the sense of protecting the CS and the TV.

In the mitral valve circle large procedure (MVA), the two large circle large yarns 10, which are placed outside the body, are respectively inserted into the coronary sinus tube 22 and the three thousand valve tube 24, and then the catheter is used. Into the body.

Then, the coronary sinus tube 22 of the tissue protection mechanism 20 wraps around the coronary sinus, and the three thousand valve tube 24 wraps around the three thousand valve leaf. In this case, the circle large thread 10 is located in the lumen of the tissue protective device in the coronary sinus part, the three thousand valve part, and the ventricular septal part, so that the circle large thread 10 is not directly contacted by the tissue, Since the outer surface is in contact with the tissues, the effect of preventing the erosion of the tissues by the circular yarns can be achieved.

The tissue protection mechanism 20 will be described in more detail as follows.

The coronary sinus tube 22 is part of the protective action against the coronary sinus (CS) and is responsible for the area from the inlet of the coronary sinus (CS) to the site where the coronary protective device (40) is located. Since the length may be different for each patient, the approximate length is estimated through an image image such as a cardiac CT before the procedure, and an appropriate length is selected in advance according to each patient. This site uses a soft and flexible catheter to avoid compression of the coronary sinus (CS). .

At the distal end of the three thousand valve tube 24 has a structure that narrows toward the end so as to cover the circle large (cercalge suture) in the ventricular septum (heart muscle, myocardium). That is, the three thousand valve tube 24 penetrates the ventricular septum (heart muscle) from the stopper portion to the distal end, and the structure narrows toward the distal end so that the three thousand valve tube can be smoothly inserted into the ventricular septum. Has

The middle portion of the three thousand valve tube 24 is provided with a stopper (RVOT exit stopper 24a) supporting an annular shape, which allows the three thousand valve tube 24 to enter the myocardium (ventricular septum, cardiac muscle) To prevent that. In addition, the length of the RVOT stopper and hinge part is three times longer than the distance between the RVOT exit and the coronary sinus opening measured using the patient's previously obtained image. Choose. That is, the three thousand valve tube 24 is designed such that the length between the hinge portion 27 and the stopper 24a is about two times longer than the length between the stopper and the distal end portion. To this end, the top of the stopper may be varied in the tube for three thousand valves, of course, it can be provided with several types of three thousand valve tubes of different lengths between the hinge portion and the stopper. The hinge portion 27, which is a portion where the coronary sinus tube 22 and the three thousand valve tube 24 are coupled, is caught by the edge of the CS inlet. In this case, the stopper 24a (RVOT exit stopper) and the hinge portion 27 of the three thousand valve tube 24 are fixed, and the three thousand valve tube 24 therebetween maintains an inverse C shape by the length thereof. The three thousand valves (TV) around the floating without being in close contact. This action serves to prevent the erosion of the three thousand valves due to the circle large yarn 10, and also serves to limit the movement of the valve leaflets less.

Three thousand valve tube 24 as a whole has a rigidity (rigidity) enough to resist the bending (kink) when tension is applied to the circle large yarn, it is designed to be flexible to the inverted C shape.

Stem portion (26) is a portion in which the tube for coronary sinus and the tube for three thousand valves are extended and coupled to each other, the end is located in the relative vein. (See FIG. 3) The stem portion 26 serves to support the tubular sinus tube (22, CS tube) and the three thousand valve tube (24, TV tube) to be in a stable position, for coronary sinus The hinge portion 27, which is a portion where the tube 22 and the three thousand valve tube 24 are coupled, is caught at the inlet side of the coronary sinus and the tissue protection mechanism 20 is further increased. Perform a function to prevent abnormalities from entering. The stem portion 26 is such that both closely attached tubes 22, 24 are made of semi-rigid catheter material.

4 is a schematic diagram of a knot delivery mechanism 30, according to a preferred embodiment of the present invention.

The knot delivery mechanism 30 of the present invention transfers the knot of the circular yarn to the upper end of the tissue protection mechanism 20 in order to transmit and maintain a constant tension to the circular yarn, and then fix the tension of the circular yarn with the knot. , A mechanism for maintaining.

In mitral valve circle large surgery (MVA), one of the important processes is the need for a mechanism to transmit and maintain tension to compress the mitral valve. These instruments should (1) be easy to perform, (2) easily adjust the tension of the circle large thread for each patient, and (3) easily fix it again, and (4) the circle large thread once fixed ( After the procedure), it should not be released and maintain a constant tension at all times.

In Figure 4 as an embodiment of the knot delivery mechanism, (a) shows a state that the opening and closing part is closed, (b) shows a state that the opening and closing portion is open.

The knot delivery mechanism is a catheter formed with an opening and closing portion 32 which can be opened and closed at one end and a through hole 34 at the side of the opening and closing portion in the longitudinal direction. That is, the diagnostic catheter has a lumen. The material may be a rubber or plastic material having a ductility to be inserted into the body from the outside.

As shown in (a), when the opening and closing part is closed, a knot is made in the opening and closing part using a circle large thread outside the body, and then the knot delivery mechanism is put in a specific position in the body and then the tension of the circle large thread is adjusted appropriately. Then, open and close the opening as shown in (b), so that the circle large yarn is tied to the knot while maintaining the tension.

The knot delivery mechanism 30 will be described in more detail with reference to FIG. 5.

Figure 5 is a state diagram of use of the device for mitral valve circle large surgery, according to a preferred embodiment of the present invention.

Referring to FIG. 5, first, two ends of the circular yarns 10 that have been released into the body are inserted into the through holes 34 formed at the ends of the knot delivery mechanism 30 to form knots. Pass through the lumen of the knot delivery mechanism 30 (a).

after that. The knot delivery device 30 is pushed toward the heart to place the end of the knot delivery device 30 at the upper end of the tissue protection device 20. As such, the knot delivery mechanism 30 has a function of transmitting while maintaining the knot is not tightened through the through hole 34.

Then, by applying tension to the circle large yarn 10 to adjust the appropriate tension until mitral regurgitation disappears. That is, the tension of the circle large thread is adjusted while pulling or releasing both ends of the circle large thread in vitro until mitral regurgitation disappears (b).

When the appropriate tension is reached, the opening and closing portion of the knot delivery mechanism 30 is opened. Opening of the opening and closing part may be used in various ways such as cutting the opening and closing part by a cutter or the like, or the method as illustrated in FIG. 4 described below.

In this case, the knot, which could not be tightened by the opening and closing part, is tightened, and the tension of the circle large thread is fixed (d). That is, the end of the circle large yarn 10 is fixed with a knot (12). In this state, the lumen of the stem reaches the knot in the form of 'side-by-side' of the two large circle threads, so the knot is maximally resistant to loosening despite the relatively high tension.

In this state, the circular large thread 10 is cut at a point away from the knot using a cutter, and then the remaining portion of the circular large thread 10 and the knot delivery mechanism 30 are taken out of the body (e).

Thus, the circle large yarn is completed by the procedure of mitral regurgitation by wrapping the coronary sinus (CS) and three thousand valves (TV) by the tissue protection mechanism 20 while maintaining a constant tension (f).

6 is a schematic diagram of a knot delivery mechanism, according to another preferred embodiment of the present invention. The knot delivery mechanism shown in FIG. 6 illustrates a method other than a method of cutting and opening the opening and closing part.

Referring to FIG. 6, the knot delivery mechanism 30 includes an external first tube 36 and a second tube 38 inserted into the first tube and rotatable within the first tube. The opening and closing part 32 is opened or closed by the rotation of the tube or the second tube 38. The first tube and the second tube are basically a kind of catheter.

(a) shows a state in which the opening and closing part is closed, and in this state, the opening and closing part is opened by rotating the first tube or rotating the second tube, and (b) shows a state in which the opening and closing part is opened.

As shown, the first tube 36 has a hole 37 having a length corresponding to the sum of the opening and closing portion length L1 and the length L2 of the through hole at one end. At this time, the width d1 of the hole is equal to the width of the opening and closing portion and the width of the through hole.

 And, the second tube 38 has a hole 39 having a length greater than or equal to the length of the first tube hole 37, the length of the hole 39 is equal to the length (L1) of the opening and closing portion and the width (d2) The inlet portion 39a which is equal to or larger than the width d1 of the opening and closing portion, and the inner portion whose length is greater than or equal to the length L2 of the through hole and whose width d3 is larger than the sum of the width d2 of the inlet portion and the width d1 of the through hole ( 39b).

Accordingly, when the first tube or the second tube is rotated in the state in which the opening and closing part is closed, the opening and closing part is in the open state, which can be used as the knot delivery mechanism 20.

The foregoing descriptions are merely examples according to preferred embodiments, and the scope of the present invention is not limited to the above embodiments. The technical scope of the present invention is shown in the claims, and various changes, substitutions, and alterations can be made by those skilled in the art without departing from the spirit or scope of the invention described in the claims.

1 is a schematic diagram of a tissue protection apparatus, in accordance with a preferred embodiment of the present invention.

Figure 2 is a front incision view of the heart showing the tissue protection mechanism is installed, according to a preferred embodiment of the present invention.

Figure 3 is a side incision view of the heart showing a tissue protection mechanism is installed, according to a preferred embodiment of the present invention.

4 is a schematic representation of a knot delivery mechanism, in accordance with a preferred embodiment of the present invention.

Figure 5 is a state of use of the device for mitral valve circle large surgery, according to a preferred embodiment of the present invention.

6 is a schematic representation of a knot delivery mechanism, in accordance with another preferred embodiment of the present invention.

Description of the Related Art [0002]

10: cerclage suture 12: knot

20: tissue protection organization

22: coronary sinus tube (CS tube)

24: tricuspid valve tube (TV tube)

24a: stopper (RVOT exit stopper)

26: stem

27: hinge portion

30: knot delivery device 32: opening and closing portion

34: through

36: first tube 37: hole

38: second tube 39: hole

39a: inlet part 39b: inner part part

40: coronary protective device

Claims (17)

In the device for mitral valve circle large procedure to protect the tissues of the coronary sinus and three thousand valves, and to deliver the knot to maintain the tension of the circle large thread, (A) Coronary sinus tube 22, which is a hollow cylindrical tube for protecting coronary sinus tissue, a triangular valve tube 24, which is a hollow cylindrical tube for protecting tissues of the tricuspid valve and ventricular septum, and A tissue protection mechanism (20) consisting of a stem portion (26) in which the tubular sinus tube and the three thousand valve tube are extended and fixed to each other; And (B) a hollow catheter, a knot delivery mechanism 30 having an opening and closing portion 32 that can be opened and closed at one end and a through hole 34 formed at a side of the opening and closing portion in a longitudinal direction;  Apparatus for mitral valve circle large surgery, comprising a. The method of claim 1, Apparatus for mitral valve circle large surgery, characterized in that the stopper 24a is formed in the middle portion of the three thousand valve tube 24 to prevent the three thousand valve tube from entering the myocardium. 3. The method of claim 2, The stopper is a device for mitral valve circle surgery, characterized in that the annular projection. The method of claim 1, The device for mitral valve circle large surgery, characterized in that the three thousand valve tube has a structure that is tapered toward the end so as to wrap the circle large yarn in the ventricular septum. The method of claim 1, The tubular sinus tube 22 is used a material having a soft and flexible, The three thousand valve tube 24 and the stem portion 26 is a device for mitral valve circle large surgery, characterized in that a relatively strong material is used as compared to the tube for coronary sinus. The method of claim 1, Apparatus for mitral valve circle large surgery, characterized in that the opening and closing of the knot delivery mechanism is cut open by the cutter. The method of claim 1, The knot delivery mechanism 30 is composed of an external first tube 36 and a second tube 38 inserted into the first tube and rotatable within the first tube. Apparatus for mitral valve circle large surgery, characterized in that the opening and closing portion 32 is opened or closed by the rotation of the second tube (38). The method of claim 7, wherein The first tube 36 is formed with a hole 37 having a length corresponding to the sum of the opening and closing portion length L1 and the length L2 of the through hole at one end thereof, The second tube 38 has a hole 39 having a length greater than the length of the first tube hole 37, The hole 39 has an inlet portion 39a whose length is equal to the length L1 of the opening and closing portion, and the width d2 is greater than or equal to the width d1 of the opening and closing portion, and the length is greater than or equal to the length L2 of the opening and the width d3 is Apparatus for mitral valve circle large surgery, characterized in that the inner portion (39b) is larger than the sum of the width (d2) of the inlet portion and the width (d1) of the through hole. In the tissue protection mechanism for protecting the tissue of the coronary sinus and three thousand valves in the mitral valve circle large procedure, Coronary sinus tube 22, which is a hollow cylindrical tube for protecting coronary sinus tissue, Three thousand valve tube 24 which is a hollow cylindrical tube for protecting the tricuspid valve and the tissues of the ventricular septum, and The coronary sinus tube and the three thousand valve tube for extending the tissue protection mechanism comprising a stem portion 26 is fixed to each other. The method of claim 9, A tissue protector, characterized in that the stopper (24a) is formed in the middle portion of the three thousand valve tube 24 to prevent the three thousand valve tube from entering the myocardium. The method of claim 10, The stopper (24a) is a tissue protection mechanism, characterized in that the annular projection. The method of claim 9, The three thousand valve tube is tissue protection mechanism characterized in that it has a structure that is tapered toward the end, so as to wrap the circle large yarn in the ventricular septum. The method of claim 9, The tubular sinus tube 22 is used a material having a soft and flexible, The three thousand valve tube 24 and the stem portion 26 is a tissue protection mechanism, characterized in that a relatively strong material is used as compared to the tube for coronary sinus. In the knot delivery mechanism for transmitting and maintaining the knot of the circle large thread to maintain the tension of the circle large thread in the mitral valve circle large procedure, The knot delivery mechanism is a hollow catheter, knot delivery mechanism characterized in that the opening and closing portion 32 which can be opened and closed at one end and a through hole 34 formed in the side of the opening and closing portion in the longitudinal direction. 15. The method of claim 14, A knot delivery mechanism, characterized in that the opening and closing portion of the knot delivery mechanism is cut open by a cutter. 15. The method of claim 14, The knot delivery mechanism 30 is composed of an external first tube 36 and a second tube 38 inserted into the first tube and rotatable within the first tube. Knot delivery mechanism, characterized in that the opening and closing portion 32 is opened or closed by the rotation of the second tube (38). The method of claim 16, The first tube 36 is formed with a hole 37 having a length corresponding to the sum of the opening and closing portion length L1 and the length L2 of the through hole at one end thereof, The second tube 38 has a hole 39 having a length greater than the length of the first tube hole 37, The hole 39 has an inlet portion 39a whose length is equal to the length L1 of the opening and closing portion, and the width d2 is greater than or equal to the width d1 of the opening and closing portion, and the length is greater than or equal to the length L2 of the opening and the width d3 is A knot delivery mechanism comprising an inner portion 39b that is larger than the sum of the width d2 of the inlet portion and the width d1 of the through hole.

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